U.S. patent application number 17/313938 was filed with the patent office on 2021-08-26 for method of personalized treatment for cardiomyopathy and heart failure and other related diseases by measuring renin activity, pro-renin, pro-renin receptor levels in blood.
The applicant listed for this patent is ARIZONA BOARD OF REGENTS ON BEHALF OF THE UNIVERSITY OF ARIZONA. Invention is credited to Inna Gladysheva, Guy Reed, Ryan Sullivan, Ranjana Tripathi.
Application Number | 20210262008 17/313938 |
Document ID | / |
Family ID | 1000005622176 |
Filed Date | 2021-08-26 |
United States Patent
Application |
20210262008 |
Kind Code |
A1 |
Reed; Guy ; et al. |
August 26, 2021 |
METHOD OF PERSONALIZED TREATMENT FOR CARDIOMYOPATHY AND HEART
FAILURE AND OTHER RELATED DISEASES BY MEASURING RENIN ACTIVITY,
PRO-RENIN, PRO-RENIN RECEPTOR LEVELS IN BLOOD
Abstract
Methods of using measured plasma renin activity assayed (PRA),
plasma renin activity concentration (PRAC), active renin
concentration (ARC), plasma renin activity concentration (PRAC)
and/or active plasma renin concentration (APRC), pro-renin
activity, (pro)-renin receptor (PRR) levels for diagnosing,
prognosing, treating and monitoring heart failure (HF) or
HF-associated conditions or other conditions that cause or are
caused by altered (e.g., elevated) renin activity, pro-renin
levels, PRR levels, PRC, APRC, and/or interaction of renin or
pro-renin with PRR. These methods can be used for at-risk patients
for personalized therapy of heart disease to reduce heart
dysfunction progression, diminish HF, and prolong life. This
technology stratifies patients with HF or those at risk for HF to
determine the appropriate medication (agents that specifically
interfere with plasma renin activity/pro-renin and/or PRR) or
intervention and the appropriate dosage of medication to treat
further HF progression.
Inventors: |
Reed; Guy; (Phoenix, AZ)
; Gladysheva; Inna; (Phoenix, AZ) ; Sullivan;
Ryan; (Phoenix, AZ) ; Tripathi; Ranjana;
(Phoenix, AZ) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
ARIZONA BOARD OF REGENTS ON BEHALF OF THE UNIVERSITY OF
ARIZONA |
Tucson |
AZ |
US |
|
|
Family ID: |
1000005622176 |
Appl. No.: |
17/313938 |
Filed: |
May 6, 2021 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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PCT/US19/60078 |
Nov 6, 2019 |
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17313938 |
|
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62756427 |
Nov 6, 2018 |
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Current U.S.
Class: |
1/1 |
Current CPC
Class: |
A61K 31/16 20130101;
A61P 9/04 20180101; C12Q 1/37 20130101; G01N 33/573 20130101; G01N
2800/325 20130101; G01N 2800/52 20130101; G01N 2333/96483
20130101 |
International
Class: |
C12Q 1/37 20060101
C12Q001/37; A61K 31/16 20060101 A61K031/16; G01N 33/573 20060101
G01N033/573; A61P 9/04 20060101 A61P009/04 |
Claims
1. A method for treating a patient who is suffering from a heart
condition, the method comprising the steps of: a. determining if
the patient has increased plasma renin activity by: i. obtaining a
blood sample from the patient; ii. measuring plasma renin activity,
and/or measuring pro-renin activity and/or measuring (pro)-renin
receptor (PRR) levels, wherein plasma renin activity comprises
plasma renin activity (PRA), plasma renin activity concentration
(PRAC), active renin concentration (ARC), and/or active plasma
renin concentration (APRC); iii. determining a status of the heart
condition in said patient or risk of death of said patient based on
measured PRA, PRAC, ARC, and/or APRC, and/or measured pro-renin
activity and/or measured PRR levels; and b. if the patient has an
increase of plasma renin activity of more than 5% compared to a
baseline level, administering a treatment to the patient.
2. The method of claim 1, wherein the heart condition comprises
heart failure (HF), HF-associated and
non-associated-sarcopenia/cachexia, -necrosis, -liver disease,
and/or -kidney disease, HF-reduced ejection fraction (HFrEF),
HF-preserved ejection fraction (HFpEF), or heart dysfunction.
3. The method of claim 1, wherein plasma renin activity comprises
expression and/or activity level of renin pathway family
members.
4. The method of claim 1, wherein said measuring plasma renin
activity (PRA) comprises measuring expression and/or activity level
of renin pathway family members.
5. The method of claim 1, wherein a baseline level comprises plasma
renin activity levels from a healthy subject, wherein the healthy
subject is a subject without said heart condition.
6. The method of claim 1, wherein the baseline level comprises
plasma renin activity levels previously measured from the patient
at a time of initial presentation or diagnosis of said heart
condition.
7. The method of claim 1, wherein said treatment comprises
therapeutically effective drugs or intervention that modulate
extracellular water content.
8. The method of claim 7, wherein said therapeutically effective
drugs comprise direct and indirect renin inhibitors and inhibitors
to the renin pathway, which result in decrease production of active
renin, diuretics, dobutamine, epinephrine, norepinephrine, and
therapeutics against angiotensin, aldosterone, angiotensin
converting enzyme or neprilysin, beta blockers, angiotensin
receptor blockers, antiarrhythmic agents, anticoagulants,
cholesterol-lowering drugs, statins, and/or digoxin.
9. The method of claim 7, wherein said intervention comprises the
use of direct renin inhibitors in combination with diuretics,
dobutamine, and therapeutics against angiotensin, aldosterone or
neprilysin, beta blockers, antiarrhythmic agents, anticoagulants,
cholesterol-lowering drugs (e.g., statins), and/or digoxin,
additional and/or more frequent monitoring, physically draining a
cavity, exercising or nutritional alterations.
10. The method of claim 1, wherein said treatment further comprises
devices that improve or stabilize cardiac function comprising
pacemakers, defibrillators, circulatory assistance, artificial
hearts, and/or transplantation.
11. A method of monitoring effectiveness of a treatment in a
patient with a heart condition, wherein the treatment is currently
being administered to said patient, comprising the steps of: a.
determining plasma renin activity of the patient by: i. obtaining a
blood sample from the patient; ii. measuring plasma renin activity,
and/or measuring pro-renin activity and/or measuring (pro)-renin
receptor (PRR) levels wherein plasma renin activity comprises
plasma renin activity (PRA), plasma renin activity concentration
(PRAC), active renin concentration (ARC), and/or active plasma
renin concentration (APRC); and iii. determining a status of the
heart condition in said patient or risk of death of said patient
based on measured PRA, PRAC, ARC, and/or APRC, and/or measured
pro-renin activity and/or measured PRR levels; b. determining
changes in plasma renin activity compared to a baseline level;
wherein if the patient has an increase of plasma renin activity by
more than 5% compared to the baseline level, a different treatment
administered to the patient; wherein if the patient has a decrease
of plasma renin activity of more than 5% compared to the baseline
level, the patient maintains the current treatment.
12. The method of claim 11, wherein a heart condition comprises
heart failure (HF), HF-associated and
non-associated-sarcopenia/cachexia, -necrosis, -liver disease,
and/or -kidney disease, HF-reduced ejection fraction (HFrEF),
HF-preserved ejection fraction (HFpEF), or heart dysfunction.
13. The method of claim 11, wherein plasma renin activity comprises
expression and/or activity level of renin pathway family
members.
14. The method of claim 11, wherein said measuring plasma renin
activity (PRA) comprises measuring expression and/or activity level
of renin pathway family members.
15. The method of claim 11, wherein the baseline level comprises
plasma renin activity levels from a healthy subject, wherein the
healthy subject comprises a subject without said heart
condition.
16. The method of claim 11, wherein the baseline level comprises
plasma renin activity levels previously measured from the patient
at a time of initial presentation or diagnosis of said heart
condition.
17. The method of claim 11, wherein said treatment comprises
therapeutically effective drugs or intervention that modulate
extracellular water content.
18. The method of claim 17, wherein said therapeutically effective
drugs comprise direct and indirect renin inhibitors and inhibitors
to the renin pathway, which result in decrease production of active
renin, diuretics, dobutamine, epinephrine, norepinephrine, and
therapeutics against angiotensin, aldosterone, angiotensin
converting enzyme or neprilysin, beta blockers, angiotensin
receptor blockers, antiarrhythmic agents, anticoagulants,
cholesterol-lowering drugs, statins, and/or digoxin.
19. The method of claim 17, wherein said intervention comprises the
use of direct renin inhibitors in combination with diuretics,
dobutamine, and therapeutics against angiotensin, aldosterone or
neprilysin, beta blockers, antiarrhythmic agents, anticoagulants,
cholesterol-lowering drugs (e.g., statins), and/or digoxin,
additional and/or more frequent monitoring, physically draining a
cavity, exercising or nutritional alterations.
20. The method of claim 11, wherein said treatment further
comprises devices that improve or stabilize cardiac function
comprising pacemakers, defibrillators, circulatory assistance,
artificial hearts, and/or transplantation.
Description
CROSS-REFERENCES TO RELATED APPLICATIONS
[0001] This application is a continuation-in-part and claims
benefit of PCT Application No. PCT/US19/60078, filed Nov. 6, 2019,
which claims benefit of U.S. Provisional Patent Application No.
62/756,427, filed Nov. 6, 2018, the specifications of which are
incorporated herein in their entirety by reference.
BACKGROUND OF THE INVENTION
[0002] Yearly, one in every four deaths in the United States is
caused by heart disease, approximately 610,000 deaths. Currently,
heart disease is treated with lifestyle changes, medications, or
surgery. There is a need for a method of detecting heart disease
early on and a treatment plan that is personalized to the condition
of the individual patient and can prevent the progression of other
ailments that result from heart disease, including heart failure
(HF).
FIELD OF THE INVENTION
[0003] The present invention relates to methods of using measured
plasma renin activity assayed and defined as PRA, active renin
concentration (ARC), and/or active plasma renin concentration
(APRC), plasma renin activity concentration (PRAC), or other
methods; pro-renin activity, and (pro)-renin receptor (PRR) levels,
for diagnosing, prognosing, treating and monitoring HF-associated
conditions or other conditions that cause or are caused by altered
(e.g., elevated) renin activity, pro-renin levels, PRR levels, PRC,
ARC, APRC, and/or interaction of renin or pro-renin with PRR. The
methods described herein also can be used for at-risk patients for
personalized therapy of heart disease to reduce the progression of
heart dysfunction, diminish HF, and prolong life. This technology
intends to stratify patients with HF or those at risk for HF, to
determine the appropriate medication (agents that specifically
interfere with plasma renin activity/pro-renin and/or PRR) or
intervention as well as the appropriate dosage of medication to use
to help treat further progression of HF.
BACKGROUND ART
[0004] Heart failure (HF) has many causes and HF progression is
affected by various pathways, including the sympathetic nervous
system, the renin-angiotensin-aldosterone-system (RAAS) and the
natriuretic peptide (NP) system. Activation of the
angiotensin-aldosterone-system is associated with extracellular
fluid and sodium retention (edema), left ventricular dysfunction,
and cardiac dilation. Renin is an enzyme that specifically
catalyzes the first and rate limiting step in the activation of
angiotensin II, which also enhances the secretion of aldosterone.
Although pathological plasma renin activity longitudinally
increases with HF stages and varies between patient subsets,
clinical trials with non-personalized approach have failed to
confirm a crucial role for renin activity in pathogenesis of
HF.
[0005] Patients with HF or those at risk are often treated with the
same medications, based on findings from large randomized clinical
trials, which tend to homogenize individual differences. Current
treatment guidelines for HF broadly recommend therapeutics directed
against angiotensin, aldosterone, or neprilysin, without the
assessment of these (as) biomarkers, although it is widely known
that HF has many etiologies and patients show differences in their
biomarker profiles. For example, expression and activation of the
enzymes, hormones, and receptors of the RAAS are modulated by a
variety of factors including sex.
[0006] It is increasingly recognized that there are disparities in
treatment outcomes related to a variety of factors such as sex,
race, geographic location, disease etiology, and genetics causes.
For example, in a mouse model of dilated cardiomyopathy (DCM), with
translational relevance to human HF, female mice develop HF at an
accelerated rate that is indicated by worsening systolic function,
increased natriuretic peptide (NP) levels, lung edema, and reduced
survival by comparison to males. Prior to development of HF and
other biomarker abnormalities, female mice showed increased plasma
renin activity levels, linking elevated plasma renin activity
levels in female mice to accelerated, sex-related deterioration in
systolic function, HF progression, and early mortality.
[0007] There remains a need for improving detection/diagnosis,
prognosis, and treatment of cardiomyopathy and HF. This
necessitates a solution to identify specific biomarkers to aid in
developing targeted treatment plans. Improving the treatment
management of HF necessitates a personalized medicine approach,
which requires a two-prong technique that relies on 1)
identification of specific biomarkers, which allow for earlier
diagnoses and classification of a disease profile and, 2) a
targeted treatment plan for the individual based on their specific
profile (e.g., personalized treatment/precision therapy
strategy).
[0008] Commercial kits are available that detect markers of
cardiovascular disease, but do not typically include renin/plasma
renin activity/pro-renin/PRR. Cardiovascular MAP (Myriad RBM)
detects several (n=77) analytes (excluding renin) associated with
cardiovascular disease. TruSight Cardio Kit (IIlumina) uses
next-generation sequencing (NGS) to provide coverage of 174 genes
(excluding renin) with known associations to 17 inherited cardiac
conditions (ICCs), including cardiomyopathies, arrhythmias,
aortopathies, and more.
[0009] Plasma Renin Activity has been previously evaluated as a
potential predictive marker for cardiovascular disease risk and
prognostic marker for individuals with HF or other heart-related
diseases. Plasma renin activity levels have been suggestive of
cardiovascular outcomes, HF, transition to severe HF, and mortality
in limited clinical trials. However, clinical trials designed using
a non-personalized approach resulted in negative findings. In
addition, women were underrepresented in the clinical trials. In
addition, increased plasma renin activity levels did not always
correlate with higher mortality and reduction of PRA levels did not
always correlate with improved outcomes in certain populations of
patients with heart conditions. Biomarkers of HF (excluding renin)
have been proposed to determine medication(s) that will help
particular patients, and plasma renin level has been proposed as a
prognosticator of cardiac remodeling and HF. Although several
biomarkers are being evaluated to help guide more precision therapy
for HF, renin has not been considered as a biomarker for treatment
tailoring and monitoring of cardiovascular diseases, including
HF.
BRIEF SUMMARY OF THE INVENTION
[0010] It is an objective of the present invention to provide
methods that allow for diagnosing, prognosing, treating, and
monitoring conditions that cause or are caused by altered plasma
renin activity, in particular, HF-related conditions, as specified
in the independent claims. Embodiments of the invention are given
in the dependent claims. Embodiments of the present invention can
be freely combined with each other if they are not mutually
exclusive.
[0011] The present invention features use of measured plasma renin
activity as assayed by PRA, PRAC, ARC, and/or APRC, or other
methods, and/or use of measured pro-renin activity and/or use of
measured PRR levels for diagnostic, prognostic, and treatment
tailoring and monitoring purposes to aid in the personalized
management of patients at risk or with HF. As there remains a need
for an individualized/personalized treatment of HF based on
identifying specific biomarkers, physicians will be able to use the
present invention to recommend personalized treatments (i.e.,
precision medicine), a feature commonly unavailable to patients
with HF. The present invention provides a solution addressing the
industry need as earlier diagnoses and classification of disease
profiles allow physicians to conduct individualized targeted
treatment, thus improving clinical outcomes.
[0012] One of the unique and inventive technical features of the
present invention is using measured plasma renin activity as
assayed by PRA, PRAC, ARC, and/or APRC, or other methods, and/or
measured pro-renin activity and/or measured (pro)-renin receptor
(PRR) levels for personalized medicine of patients with
cardiovascular disease or HF. In particular, this invention
utilizes the resultant changes in the plasma renin activity
biomarker wherein the resultant changes are indicators (e.g.,
predictive and prognostic) for personalized treatment strategies,
prognosis, personalized treatment monitoring, and disease
progression monitoring for conditions that cause altered plasma
renin activity. Without wishing to limit the invention to any
theory or mechanism, it is believed that using plasma renin
activity, analyzed and defined as PRA, PRR, PRAC, and/or ARC,
and/or using pro-renin activity, and/or using PRR levels
advantageously provides for personalized treatment approaches for
conditions that cause altered or increased plasma renin activity,
including HF-related conditions.
[0013] Further, the prior art teach away from using plasma renin
activity assayed as PRA, ARC, PRAC, and/or APRC, or other methods
as a biomarker for personalized treatment and management of HF
because prior art have failed to confirm a crucial role for plasma
renin activity in pathogenesis or progression of HF. The present
invention showed that elevated plasma renin activity level is a
reliable biomarker of HF such that in female mice with dilated
cardiomyopathy (DCM), elevated plasma renin activity was correlated
to accelerated, sex-related deterioration in systolic function, HF
progression, and early mortality. In addition, renin, plasma renin
activity, PRA, prorenin, or PRR are typically not included in
cardiovascular panels and have not been indicated as promising
biomarkers for treatment tailoring and monitoring of cardiovascular
diseases, including HF. Reducing plasma renin activity however
occurs at the expense of an increased plasma renin concentration
(PRC), which may exert direct effects independent of plasma renin
activity through the recently discovered PPR. While active renin is
acknowledged to initiate production of both angiotensin II (Ang II)
and aldosterone, clinical studies have not rigorously examined
plasma renin activity in the pathogenesis of HF. Active renin
concentration was recently suggested as a potential indicator for
guiding HF with reduced EF (HFrEF) in addition to BNP and New York
Heart Association (NYHA) classification.
[0014] Additionally, the present invention targeted normalization
of elevated PRAC and plasma renin activity analyzed by other
methods (e.g., PRA, ARC) by direct renin inhibition using a dose
(e.g., oral dose) that does not alter the Ang II-aldosterone axis
and renin inhibition surprisingly significantly prolongs life,
preserves left ventricular function, reduces edema formation, and
delays cachexia/sarcopenia.
[0015] The present invention features in vitro methods for
determining diagnosis and prognosis of a patient (the patient can
be symptomatic or asymptomatic for HF-related conditions) who is
suspected or has a condition that causes or caused by altered
(e.g., elevated) plasma renin activity, including HF and/or
HF-related conditions. In preferred embodiments, the method
comprises first measuring plasma renin activity, PRR levels, and/or
plasma renin activity assayed and defined as PRA, PRAC, ARC, and/or
APRC (or plasma renin activity measured by other methods) in blood
from the patient. The patient is then diagnosed and/or prognosed
based on the measured plasma renin activity and/or PRR levels
and/or measured plasma renin activity as assayed and defined as
PRA, PRAC, ARC, and/or APRC (plasma renin activity also can be
measured by other methods). A personalized treatment approach for
the patient is then determined using the diagnosis and/or prognosis
based on the measured analytes (e.g., PRA, PRR levels, PRAC, ARC,
APRC, and/or plasma renin activity measured by other methods) as
well as the specific clinicopathologic characteristics (e.g., sex,
age, prior history of HF-related conditions) of the patient.
[0016] The present invention further features a method for treating
a patient that has a condition that causes or is caused by altered
(e.g., elevated) PRA, including HF and/or HF-related conditions. In
preferred embodiments, the method comprises first measuring
pro-renin activity, PRR levels, and/or plasma renin activity
assayed and defined as PRA, PRAC, ARC, and/or APRC (or plasma renin
activity measured by other methods) in blood from the patient. The
patient is then prognosed and a risk of progression is determined
based on the measured PRA, PRR levels, PRAC, ARC, and/or APRC. A
personalized treatment approach for the patient is then determined
using the prognosis based on the measured plasma renin activity
and/or PRR levels and/or measured plasma renin activity as assayed
and defined as PRA, PRAC, ARC, and/or APRC (plasma renin activity
also can be measured by other methods) as well as the specific
clinicopathologic characteristics (e.g., sex, age, prior history of
HF-related conditions) of the patient. The invention features an
additional step of administering a therapy based on agents that
specifically interfere with renin/plasma renin activity and/or
renin/plasma renin activity interaction with PRR (receptor).
[0017] The present invention also features an in vitro method for
personalized treatment monitoring for a condition that causes or is
caused by altered (e.g., elevated) plasma renin activity, including
HF and/or HF-related conditions. In preferred embodiments, the
method comprises first measuring plasma renin activity, PRR levels,
and/or plasma renin activity assayed and defined as PRA, PRAC, ARC,
and/or APRC (or plasma renin activity measured by other methods) in
blood from the patient over time. The patient is then prognosed and
a risk of progression is determined based on the measured plasma
renin activity and/or PRR levels and/or measured plasma renin
activity as assayed and defined as PRA, PRAC, ARC, and/or APRC
(plasma renin activity also can be measured by other methods) at
the different timepoints (e.g., two to seven days post-diagnosis,
one month post diagnosis, three months post diagnosis, or >three
months post-diagnosis as compared to baseline measurements at time
of diagnosis). The personalized treatment or approach for the
patient can then be changed based on the differences of the
measured analytes (e.g., plasma renin activity, PRR levels, PRA,
PRAC, ARC, APRC, and/or plasma renin activity measured by other
methods) as well as the specific clinicopathologic characteristics
(e.g., sex, age, diet, exercise, smoking history, prior history of
HF-related conditions) of the patient. In some embodiments, the
invention features an additional step, for example, changing the
therapy or requiring additional monitoring or another intervention
if the patient is progressing.
[0018] The present invention further features a method for
monitoring disease progression of conditions that cause altered
(e.g., elevated) PRA, PRA, including HF and/or HF-related
conditions. In preferred embodiments, the method comprises first
measuring plasma renin activity, PRR levels, and/or plasma renin
activity assayed and defined as PRA, PRAC, ARC, and/or APRC (or
plasma renin activity measured by other methods) in blood from the
patient over time. The patient is then prognosed and a risk of
progression is determined based on the measured plasma renin
activity and/or PRR levels and/or measured plasma renin activity as
assayed and defined as PRA, PRAC, ARC, and/or APRC (plasma renin
activity also can be measured by other methods) at the different
timepoints (e.g., two to seven days post-diagnosis, one month post
diagnosis, three months post diagnosis, or >three months
post-diagnosis as compared to baseline measurements at time of
diagnosis). A personalized treatment approach for the patient can
then be developed (if patient hasn't started treatment) or changed
based on the differences of the measured analytes (e.g., plasma
renin activity, PRR levels, PRA, PRAC, ARC, APRC, and/or plasma
renin activity measured by other methods) as well as the specific
clinicopathologic characteristics (e.g., sex, age, diet, exercise,
smoking history, prior history of HF-related conditions) of the
patient. In some embodiments, the invention features an additional
step, for example, starting a therapy or changing the therapy or
requiring additional or more frequent monitoring or another
intervention if the patient is progressing or having further
increases in plasma renin activity. In other embodiments, if the
patient is not progressing and having decreases in plasma renin
activity, the personalized treatment may not be changed and/or the
frequency of monitoring may be decreased.
[0019] Any feature or combination of features described herein are
included within the scope of the present invention provided that
the features included in any such combination are not mutually
inconsistent as will be apparent from the context, this
specification, and the knowledge of one of ordinary skill in the
art. Additional advantages and aspects of the present invention are
apparent in the following detailed description and claims.
BRIEF DESCRIPTION OF THE SEVERAL VIEWS OF THE DRAWING(S)
[0020] The features and advantages of the present invention will
become apparent from a consideration of the following detailed
description presented in connection with the accompanying drawings
in which:
[0021] FIGS. 1A, 1B, 10, and 1D show heart failure (HF) stages,
study design, and effects of aliskiren, a direct renin inhibitor
(DRI). FIG. 1A shows a schematic overview of the natural history of
HF progression, biomarker changes, and experimental design, in an
established model of dilated cardiomyopathy (DCM) in female mice.
Female mice with DCM begin to show declines in heart systolic
function (ejection fraction; EF) and increases in plasma renin
activity (PRA) around 7 weeks of age (Stage B HF), which is prior
to the development of progressive edema (Stage C HF), further
declines in systolic function, rises in atrial/B-type natriuretic
peptide (ANP/BNP) and death. Mice with DCM were randomly treated
with aliskiren (DCM+DRI) or nothing (DCM+vehicle) in drinking water
(see Examples Section). Vertical hash-mark lines indicate time
points for measurement of body composition, while echocardiography
and blood-tissue collection were completed at 90 days. FIG. 1B
shows the impact of aliskiren treatment on PRA at 90 days. FIG. 1C
shows the impact of aliskiren on angiotensin II (Ang II) at 90
days. FIG. 1D shows the impact of aliskiren on aldosterone levels
at 90 days. The number of DCM mice is indicated. For reference in
FIGS. 1B-1D, values for wild-type (WT) littermates are shown as a
dashed line (n=4). Data analyzed with one-way ANOVA and represented
as mean.+-.SE. Not significant (NS), .sup.++p<0.01,
.sup.+++p<0.001 (solid circle, WT vs. DCM+vehicle; solid square,
WT vs. DCM+DRI), *** p<0.001 (DCM+vehicle vs. DCM+DRI).
[0022] FIGS. 2A, 2B, 2C, 2D, 2E, 2F, and 2G show that direct renin
inhibitor (DRI) treatment significantly improves survival and
systolic function in mice with dilated cardiomyopathy (DCM). FIG.
2A shows Kaplan-Meier survival curves of control mice with DCM
(DCM+vehicle, red, n=13 deaths+8 censored) vs. DCM mice treated
with DRI (DCM+DRI, black, n=21 deaths+8 censored). WT (n=4) values
are provided for reference. FIG. 2B shows short axis m-mode
examples of DCM+vehicle and DCM+DRI treated mice at 90 days of age.
FIG. 2C shows left ventricular systolic function measured as
ejection fraction (EF) between DCM+vehicle and DCM+DRI mice. [EF,
wildtype (WT)=62.8%]. FIG. 2C shows left ventricular systolic
function measured as fractional shortening (FS, WT=34%) between
DCM+vehicle and DCM+DRI mice. FIG. 2E shows differences in cardiac
output (CO, WT=15.5 mL/min) between DCM+vehicle and DCM+DRI mice.
FIG. 2F shows Pearson's correlation analysis of 90-day EF vs.
survival. FIG. 2G shows Pearson's correlation analysis of cardiac
output (CO) vs. survival. DCM control mice (DCM+vehicle, solid
circle, n=20), DCM mice treated with DRI (DCM+DRI, solid square,
n=27). Differences between groups were analyzed by Mantel-Cox test
and Mann-Whitney test. Pearson's correlation coefficient (r.sub.p)
and p-values are shown. Data are represented as mean.+-.SE, *
p<0.05, ** p<0.01 (DCM+vehicle vs. DCM+DRI).
[0023] FIGS. 3A, 3B, 3C, and 3D show impact of direct renin
inhibitor, aliskiren (DRI-aliskiren) treatment on HF plasma
biomarkers in female mice with dilated cardiomyopathy. FIG. 3A
shows the impact of aliskiren on atrial natriuretic peptide (ANP)
plasma levels at 90 days. FIG. 3B shows the impact of aliskiren on
cyclic guanosine monophosphate (cGMP) plasma levels at 90 days.
FIG. 3C shows the impact of aliskiren on corin plasma levels at 90
days. FIG. 3D shows the impact of aliskiren on neprilysin plasma
levels at 90 days. DCM+vehicle (solid circles) and DRI-aliskiren
treated (DCM+DRI, solid squares) group numbers are indicated. For
reference, values for wild-type (WT) mice are shown as a vertical
dashed line (n=4). Data analyzed with one-way ANOVA and represented
as mean.+-.SE. Not significant (NS), +p<0.05, ++p<0.01 (solid
circle, WT vs. DCM+vehicle; solid square, WT vs. DCM+DRI) and ***
p<0.001 (DCM+vehicle vs. DCM+DRI).
[0024] FIG. 4 shows PRAC increases in a sex-dependent manner
throughout the course of HFrEF progression in male and female mice
with dilated cardiomyopathy (DCM). Wild type males (WT-M):
n=5-8/age group; WT females (WT-F): n=6-7/age group; DCM males
(DCM-M): n=7-8/age group; DCM females (DCM-F): n=6-8/age group.
+/solid square--Difference between WT and DCM females: ++P<0.01,
+++P<0.001; +/solid circle--Difference between WT and DCM males:
+++P<0.001; */black--Difference between DCM females and DCM
males: *** P<0.001. Time-dependent differences between sexes
(male vs. female) and differences between genotypes (WT vs. DCM)
were analyzed by two-way ANOVA with the Bonferroni posttest
correction using GraphPad Prism 8.0.2 (GraphPad Software, San
Diego, Calif., USA). Data are expressed as mean.+-.SEM. All animal
study activities were approved.
[0025] FIG. 5 shows a schematic representation of a potential role
of renin activity in the modulation of HFrEF through direct and
indirect actions. The plasma renin activity/renin pair directly and
indirectly modulates HFrEF progression.
[0026] FIG. 6 shows a schematic presentation of assay principles
used to measure enzymatic renin activity in plasma samples: Plasma
renin activity (PRA); active renin concentration (ARC)/active
plasma renin concentration (APRC); and plasma renin activity
concentration (PRAC).
[0027] FIGS. 7A and 7B show plasma renin activity concentration
(PRAC) in healthy control and heart failure (HF) patients with
systolic dysfunction. FIG. 6A shows plasma samples of healthy
control patients (normal ejection fraction, EF) and patients with
reduced (rEF) with and without symptomatic HFrEF. FIG. 6B shows
Spearman correlation of PRAC to plasma N-terminal pro-atrial
natriuretic peptide (N-ANP). All patients were males and 50-70
years old. Groups were healthy control subjects (n=16), HF with
reduced ejection fraction (HFrEF) asymptomatic (n=16), and HFrEF
symptomatic (n=15). Venous blood samples were collected using
EDTA-aprotinin tubes. This study was approved by the Institutional
Review Board, and all subjects gave their informed consent for
inclusion before they participated in this study. Data represent
mean.+-.SEM. ++P<0.01, (red, Control vs.
Asymptomatic)+++P<0.0001 (black, Control vs. Symptomatic), *
P<0.05 (Asymptomatic vs. Symptomatic HFrEF). AU=arbitrary units.
Comparisons between groups were calculated using the Mann-Whitney
test. Statistical analysis was performed with GraphPad Prism 8.0.2
(GraphPad Software, San Diego, Calif., USA). P>0.05 was
considered significant.
[0028] FIGS. 8A, 8B, 8C and 8D show the effect of cardiac
corin-Tg(i) (catalytically inactive corin) overexpression on plasma
RAAS biomarkers in female DCM mice. Plasma levels of active renin
(arbitrary units, AU) (FIG. 8A), angiotensin II (AngII) (FIG. 8B),
aldosterone (Aldo) (FIG. 8C) and angiotensin 1-7 (Ang(1-7)) (FIG.
D) in corin-Tg(i)/DCM ( ,tg,tg) and corin-WT/DCM ( ,wt,tg) mouse
groups, at 90 days of age, n=6-8 per group; dotted line represents
control levels in corin-WT/WT (wt,wt) mice. Data are represented as
mean.+-.SE, differences were analyzed (for FIGS. 8A, 8B & 8D)
by one-way-ANOVA using Newman-Keuls multiple comparison test, and
by using Kruskal-Wallis test using Dunn's multiple comparison test
(for FIG. 8C). **p<0.01, *p<0.05 (tg,tg or wt,tg vs. wt,wt);
ns=non-significant.
[0029] FIGS. 9A, 9B, 9C, 9D, and 9E show the dietary sodium
restriction activates classical and non-classical RAAS in mice with
DCM. The effect of dietary sodium restriction on plasma levels of
the classical RAAS: renin activity (AU, arbitrary units) (FIG. 9A),
angiotensin II (AngII) (FIG. 9B), aldosterone (FIG. 9C), and
counter-regulatory RAAS: angiotensin converting enzyme 2 (ACE2)
(FIG. 9D) and angiotensin (1-7) (Ang (1-7)) (FIG. 9E) were
determined. Number of DCM mice n=7-8 per group. WT control mice
(dashed line, n=5-8) at 17 weeks of age. Data are presented as
mean.+-.SEM. ****p<0.0001, ***p<0.001, *p<0.001 (DCM vs.
WT); ++++p<0.0001, ++p<0.01, +p<0.05 (DCM on NSD (normal
sodium diet) vs. DCM on LSD (low sodium diet)) by one-way ANOVA
with Newman-Keuls multiple comparison test.
DETAILED DESCRIPTION OF THE INVENTION
Acronyms
[0030] ANP: atrial natriuretic peptide
[0031] APRC: active plasma renin concentration
[0032] ARC: active renin concentration activity
[0033] BNP: B-type natriuretic peptide
[0034] cGMP: cyclic guanosine monophosphate
[0035] CO: cardiac output
[0036] DCM: dilated cardiomyopathy
[0037] DRI: direct renin inhibitor
[0038] EF: ejection fraction
[0039] HF: heart failure
[0040] HFrEF: heart failure reduced ejection fraction
[0041] HFpEF: heart failure preserved ejection fraction
[0042] NP: natriuretic peptide
[0043] NYHA: New York Heart Association
[0044] PRA: plasma renin activity
[0045] PRAC: plasma renin activity concentration
[0046] PRR: pro-renin receptor
[0047] RAAS: renin-angiotensin-aldosterone-system
[0048] WT: wildtype
[0049] As used herein, the term "cardiovascular disease" refers to
conditions of the heart including structural and functional
abnormalities. Non-limiting examples comprise: heart failure (HF; a
progressive heart disease that affects pumping action of the heart
muscles as described herein); tachycardia (a heart rhythm disorder
with heartbeats faster than usual, greater than 100 beats per
minute in people); cardiomyopathy (an acquired or inherited disease
of the heart muscle which makes it difficult for the heart to pump
blood to other parts of the body); coronary artery disease (a
condition where the major blood vessels supplying the heart are
narrowed); angina (chest discomfort or shortness of breath caused
when heart muscles receive insufficient oxygen-rich blood);
ventricular tachycardia (fast heart beat rhythm of the ventricles),
myocardial infarction (death of heart muscle caused by a loss of
blood supply); congenital heart defect (abnormality in the heart
that develops before birth); atrial fibrillation (a disease of the
heart characterized by irregular and often faster heartbeat);
ventricular fibrillation (a serious heart rhythm problem in which
the heart beats quickly and out of rhythm).
[0050] As used herein, "administering" and the like refer to the
act of physically delivering a composition or other therapy (e.g. a
DRI, e.g., aliskiren) described herein into a subject by such
routes as oral, mucosal, topical, transdermal, suppository,
intravenous, parenteral, intraperitoneal, intramuscular,
intralesional, intrathecal, intranasal or subcutaneous
administration. Parenteral administration includes intravenous,
intramuscular, intra-arterial, intradermal, subcutaneous,
intraperitoneal, intraventricular, and intracranial administration.
When a disease, disorder or condition, or a symptom thereof, is
being treated, administration of the substance typically occurs
after the onset of disease, disorder or condition or symptoms
thereof. When a disease, disorder or condition, or symptoms
thereof, are being prevented, administration of the substance
typically occurs before the onset of the disease, disorder or
condition or symptoms thereof.
[0051] As used herein, the terms "subject" and "patient" are used
interchangeably. As used herein, a subject can be an animal
(amphibian, reptile, avian, fish, or mammal) such as a non-primate
(e.g., cows, pigs, horses, cats, dogs, rats, etc.) or a primate
(e.g., monkey, ape and human). In specific embodiments, the subject
is a human. In one embodiment, the subject is a mammal (e.g., a
human, a dog) having a disease, disorder or condition described
herein. In another embodiment, the subject is a mammal (e.g., a
human, a dog) at risk of developing a disease, disorder or
condition described herein. In certain instances, the term patient
refers to a human under medical care or animals under veterinary
care.
[0052] The terms "treating" or "treatment" refer to any indicia of
success or amelioration of the progression, severity, and/or
duration of a disease, pathology or condition, including any
objective or subjective parameter such as abatement; remission;
diminishing of symptoms or making the injury, pathology or
condition more tolerable to the patient; slowing in the rate of
degeneration or decline; making the final point of degeneration
less debilitating; or improving a patient's physical or mental
well-being.
[0053] The term "effective amount" as used herein refers to the
amount of a therapy or medication (e.g., DRI provided herein) which
is sufficient to reduce and/or ameliorate the severity and/or
duration of a given disease, disorder or condition and/or a symptom
related thereto. This term also encompasses an amount necessary for
the reduction or amelioration of the advancement or progression of
a given disease (e.g., cardiovascular), disorder or condition,
reduction or amelioration of the recurrence, development or onset
of a given disease, disorder or condition, and/or to improve or
enhance the prophylactic or therapeutic effect(s) of another
therapy. In some embodiments, "effective amount" as used herein
also refers to the amount of therapy provided herein to achieve a
specified result.
[0054] As used herein, and unless otherwise specified, the term
"therapeutically effective amount" of an DRI described herein is an
amount sufficient enough to provide a therapeutic benefit in the
treatment or management of a cardiovascular disease, or to delay or
minimize one or more symptoms associated with the presence of the
cardiovascular disease. A therapeutically effective amount of an
agent (e.g., DRI) described herein, means an amount of therapeutic
agent, alone or in combination with other therapies, which provides
a therapeutic benefit in the treatment or management of the
cardiovascular disease. The term "therapeutically effective amount"
can encompass an amount that improves overall therapy, reduces or
avoids symptoms or causes of cardiovascular disease, or enhances
the therapeutic efficacy of another therapeutic agent.
[0055] A therapy is any protocol, method and/or agent that can be
used in the prevention, management, treatment and/or amelioration
of a given disease, disorder or condition. In certain embodiments,
the terms "therapies" and "therapy" refer to a drug therapy,
biological therapy, supportive therapy, radiation therapy, and/or
other therapies useful in the prevention, management, treatment
and/or amelioration of a given disease, disorder or condition known
to one of skill in the art such as medical personnel.
[0056] Companion Diagnostic (CDx) assays, as defined by the FDA,
are in vitro diagnostics (IVD) devices that provide information
essential for the safe and effective use of a corresponding
therapeutic product. The FDA specifies three main areas where a CDx
assay is essential: 1) Identify patients who are most likely to
benefit from a particular therapeutic product; 2) Identify patients
likely to be at increased risk of serious adverse reactions as a
result of treatment with a particular therapeutic product; and 3)
To monitor response to treatment for the purpose of adjusting
treatment (e.g., schedule, dose, discontinuation) and to achieve
improved safety or effectiveness. A CDx can be used both to predict
outcome (efficacy and safety) and to monitor response. The FDA has
approved or cleared 35 CDx devices (as of 2018), which are
available for the treatment of specific leukemias, gastrointestinal
tumors, breast cancers, ovarian cancers, melanomas, lung cancers,
and colorectal cancers, while no approved CDx assays are available
for the treatment of HF, HF-associated and
non-associated-sarcopenia/cachexia, -necrosis, -liver disease,
-kidney disease, HFrEF, or any condition or treatment that causes
or caused by altered plasma renin activity, prorenin or PRR
levels.
[0057] As described herein, the term "asymptomatic" may refer to a
subject without a condition as described herein. In another
embodiment, the term "asymptomatic" may refer to a patient
diagnosed with a condition (e.g. heart failure) but currently has
no symptoms of the condition. In further embodiments, the term
"asymptomatic" may refer to a patient diagnosed with a condition
(e.g. heart failure) but has responded to previous therapy and
displays no symptoms of said condition.
[0058] Referring now to FIGS. 1A-9E, the present invention features
a new method for developing personalized treatment strategies for
conditions that cause or are caused by altered plasma renin
activity and/or renin/plasma renin activity interaction with PRR
using plasma renin activity for diagnostic purposes. This
technology allows for a method to use plasma renin activity to
classify disease profiles for prognosis and treatment tailoring and
monitoring strategies for disease conditions that cause or are
caused by altered PRA and/or renin/plasma renin activity
interaction with PRR. In some embodiments, the present invention
uses changes in plasma renin activity as indicators for HF
prognosis, disease progression, and personalized treatment and
monitoring strategies.
[0059] Non-limiting examples of the advantages of this technology
comprise: 1) personalized medicine strategies for optimal
individual treatment for heart disease, HF and/or HF-related
conditions; 2) ability to stratify patients with HF or those at
risk for HF; 3) preventing progression of systolic heart disease;
and 4) treat heart disease.
[0060] The present invention features a method for treating a
patient who is suffering from a heart condition. In some
embodiments, the method comprises determining if the patient has
increased plasma renin activity by 1: obtaining a blood sample from
the patient and measuring plasma renin activity, and/or measuring
pro-renin activity and/or measuring (pro)-renin receptor (PRR)
levels and 2: determining a diagnosis or prognosis of said
condition based on measured PRA, PRAC, ARC, and/or APRC, and/or
measured pro-renin activity and/or measured PRR levels. In some
embodiments, plasma renin activity comprises plasma renin activity
(PRA), plasma renin activity concentration (PRAC), active renin
concentration (ARC), and/or active plasma renin concentration
(APRC). In other embodiments, plasma renin activity is assayed and
defined as plasma renin activity (PRA), plasma renin activity
concentration (PRAC), active renin concentration (ARC), and/or
active plasma renin concentration (APRC). In some embodiments, if
the patient has an increase of plasma renin activity of more than
5% compared to a baseline level, a treatment is administered to the
patient.
[0061] The present invention may also feature a method of
monitoring effectiveness of a treatment in a patient with a heart
condition. In some embodiments, the method comprises determining if
the patient has increased plasma renin activity by 1: obtaining a
blood sample from the patient and measuring plasma renin activity
and/or measuring pro-renin activity and/or measuring (pro)-renin
receptor (PRR) levels and 2: determining a diagnosis or prognosis
of said condition based on measured PRA, PRAC, ARC, and/or APRC,
and/or measured pro-renin activity and/or measured PRR levels. In
some embodiments, plasma renin activity comprises plasma renin
activity (PRA), plasma renin activity concentration (PRAC), active
renin concentration (ARC), and/or active plasma renin concentration
(APRC). In other embodiments, plasma renin activity is assayed and
defined as plasma renin activity (PRA), plasma renin activity
concentration (PRAC), active renin concentration (ARC), and/or
active plasma renin concentration (APRC). In some embodiments,
monitoring the effectiveness of the treatment in the patient with a
heart condition is determined by changes in plasma renin activity
compared to a baseline level. In some embodiments, if the patient
has an increase of plasma renin activity of more than 5% compared
to a baseline level, a different treatment is administered to the
patient. In other embodiments, wherein if the patient has a
decrease of plasma renin activity more than 5% compared to a
baseline level, the patient maintains the same treatment.
[0062] In some embodiments, the heart condition comprises heart
failure (HF), HF-associated and non-associated-sarcopenia/cachexia,
-necrosis, -liver disease, and/or -kidney disease, HF-reduced
ejection fraction (HFrEF), HF-preserved ejection fraction (HFpEF),
heart dysfunction.
[0063] In some embodiments, if the patient has an increase of
plasma renin activity of more than about 5% compared to a baseline
level, a treatment is administered to the patient. In some
embodiments, if the patient has an increase of plasma renin
activity of more than about 6% compared to a baseline level, a
treatment is administered to the patient. In some embodiments, if
the patient has an increase of plasma renin activity of more than
about 7% compared to a baseline level, a treatment is administered
to the patient. In some embodiments, if the patient has an increase
of plasma renin activity of more than about 8% compared to a
baseline level, a treatment is administered to the patient. In some
embodiments, if the patient has an increase of plasma renin
activity of more than about 9% compared to a baseline level, a
treatment is administered to the patient. In some embodiments, if
the patient has an increase of plasma renin activity of more than
about 10% compared to a baseline level, a treatment is administered
to the patient. In some embodiments, if the patient has an increase
of plasma renin activity of more than about 12% compared to a
baseline level, a treatment is administered to the patient. In some
embodiments, if the patient has an increase of plasma renin
activity of more than about 15% compared to a baseline level, a
treatment is administered to the patient.
[0064] In some embodiments, a plasma renin activity of more than
20% above baseline indicates a pathological value. In some
embodiments, a plasma renin activity of greater than 20% above
baseline in combination with other diagnostic tools may be used to
diagnose a patient with a condition described herein.
[0065] In some embodiments, if the patient has a decrease of plasma
renin activity of about 5% compared to a baseline level, a
treatment is administered to the patient. In some embodiments, if
the patient has a decrease of plasma renin activity of about 6%
compared to a baseline level, a treatment is administered to the
patient. In some embodiments, if the patient has a decrease of
plasma renin activity of about 7% compared to a baseline level, a
treatment is administered to the patient. In some embodiments, if
the patient has a decrease of plasma renin activity of about 8%
compared to a baseline level, a treatment is administered to the
patient. In some embodiments, if the patient has a decrease of
plasma renin activity of about 9% compared to a baseline level, a
treatment is administered to the patient. In some embodiments, if
the patient has a decrease of plasma renin activity of about 10%
compared to a baseline level, a treatment is administered to the
patient. In some embodiments, if the patient has a decrease of
plasma renin activity of about 12% compared to a baseline level, a
treatment is administered to the patient. In some embodiments, if
the patient has a decrease of plasma renin activity of about 15%
compared to a baseline level, a treatment is administered to the
patient.
[0066] In some embodiments, a treatment is administered to a
patient until plasma renin activity levels reach normalization. As
used herein, "normalization" refers to age and sex matched range
(median+/-SD) for healthy/non-diseased population. In other
embodiments, the treatment administered to the patient is the same
treatment, at a higher lower dose.
[0067] In some embodiments, the treatment administered to the
patient is a different treatment. In other embodiments, the
different treatment administered to the patient is the same
treatment, at a higher dose. In some embodiments, the patient is
administered the same treatment in combination with another
treatment. In other embodiments, the treatment administered to the
patient is the same treatment, at a higher lower dose.
[0068] In some embodiments, the patient has no increase of plasma
renin activity compared to a baseline level then the treatment
administered to the patient is the same treatment.
[0069] Clinicians are restricted to ACC/AHA Guidelines, hospital
protocols, and general best practices for administering or
prescribing maximum therapeutic doses. Without wishing to limit the
present invention to any theories or mechanisms it is believed
that, heart failure patients may develop a tolerance or lack of
effect to a particular therapy (e.g., ACE inhibitors) overtime.
Changes in medications or treatment strategies should be initiated
when there is a lack of response to pathological values of PRA
(>20% normal) despite having reached maximum therapeutic
dose(s). When this occurs, clinicians should pivot therapy to a
different class of drug either independently or synergistically
with the original therapy. The goal is to normalize PRA levels and
titrate therapeutic doses to the lowest effective dose in order to
minimize side effects. Patients can be measured longitudinally to
adjust therapies on an as needed basis, resulting in a personalized
medicine approach to heart failure treatment.
[0070] In appropriate circumstances, the condition that may in part
caused by altered plasma renin activity and/or renin/plasma renin
activity interaction with PRR comprises HF, HF-associated and
non-associated sarcopenia/cachexia, necrosis, liver disease, kidney
disease, HFrEF, or any condition or treatment that causes or caused
by altered plasma renin activity, prorenin or PRR levels. In
preferred embodiments, HF comprises HF-associated and
non-associated-sarcopenia/cachexia, -necrosis, -liver disease,
and/or -kidney disease, HFrEF, HF with preserved ejection fraction
(HFpEF), ascites, organ hypoperfusion, shock, and/or cardiovascular
disease. In some embodiments, plasma renin activity comprises the
expression and/or activity of renin pathway family members and
measuring plasma renin activity comprises measuring the expression
and/or activity of renin pathway family members.
[0071] In some embodiments, the present invention may be used in
combination with other diagnostic methods to accurately diagnose a
patient with a condition that causes or is caused by plasma renin
activity. In some embodiments, plasma renin activity assayed and
defined as plasma renin activity (PRA), plasma renin activity
concentration (PRAC), active renin concentration (ARC), and/or
active plasma renin concentration (APRC), and/or measuring
pro-renin activity and/or measuring (pro)-renin receptor (PRR)
levels are biomarkers that may be used in combination with
Echocardiography, cMRI, and other clinical factors to help confirm
the Stage of HF. In other embodiments, plasma renin activity helps
determine the stage of progression for a particular condition
described herein.
[0072] The present invention further features that the expression
and/or activity of renin pathway family members are measured
longitudinally. Changes in the expression and/or activity of renin
pathway family members are detected longitudinally and longitudinal
levels can be compared to baseline levels. In some embodiments,
pro-renin level, plasma renin activity, PRA, PRR, PRAC, ARC, and/or
APRC measurement is performed in asymptomatic individuals, wherein
asymptomatic individuals are individuals without the condition. In
appropriate circumstances, baseline levels are normal levels from
an aggregate population of asymptomatic individuals without the
condition. In other circumstances, baseline levels are relative
baseline levels at the time of initial diagnosis of the condition.
In preferred embodiments, PRA can be measured at various times,
longitudinally, throughout progression of the condition.
Non-limiting examples of the timing comprise: 1) at time of
diagnosis or initial presentation of symptoms; 2) 12 hours
post-diagnosis; 3) two to seven days post-diagnosis, 4) one month
post-diagnosis, 5) three months post-diagnosis, or 6) >three
months post-diagnosis. In some embodiments, the change in pro-renin
level, plasma renin activity, PRA, PRR, PRAC, ARC, and/or APRC is
5% to 10% of baseline, 10% to 20% of baseline, 20% to 50% of
baseline, or >50% of baseline. In some embodiments, the change
in lean muscle mass level is 5% to 10% of baseline, 10% to 20% of
baseline, 20% to 50% of baseline, or >50% of baseline. In some
embodiments, the change in fat level is 5% to 10% of baseline, 10%
to 20% of baseline, 20% to 50% of baseline, or >50% of
baseline.
[0073] In some embodiments, the therapeutically effective drugs
comprise direct and indirect inhibitors to the renin pathway, which
result in decreased renin/pro-renin activity and/or renin/pro-renin
interaction with PRR without affecting the Ang II-aldosterone axis.
A non-limiting example of the dose range for DRIs comprises 75-600
mg/person, preferably 300 mg/person dose by historical human
patient hypertension trials. In other embodiments, the dose of
renin inhibitor without affecting the Ang II-aldosterone axis is
based on the individual patient; for example, in animals the dose
is <50 mg/kg; while not provided for humans in the current
literature, doses as low as 75 mg/person have been shown to
modulate blood pressure in people. In other embodiments, the
therapeutically effective drugs comprise diuretics (e.g., carbonic
anhydrase inhibitors), dobutamine, epinephrine, vasodilators,
therapeutics against angiotensin, aldosterone or neprilysin, which
may be used in combination with direct and/or indirect renin
inhibitors. Non-limiting examples of interventions comprise
additional or more frequent monitoring and lifestyle changes, for
example in diet, exercise, smoking, etc. In some embodiments, other
treatments for HF comprise devices that improve or stabilize
cardiac function such as pacemakers, defibrillators, circulatory
assist devices, artificial hearts and/or heart transplantation.
[0074] In some embodiments, the therapeutically effective drugs for
heart dysfunction and HF comprise diuretics (e.g. chlorothiazide,
HCTZ lasix), beta blockers, Angiotensin converting enzyme
inhibitors (ACE inhibitors), Angiotensin II receptor blockers
(ARBs), Angiotensin Receptor-Neprilysin Inhibitors (ARNi),
Mineralocorticoid Receptor Antagonists (MRA), direct renin
inhibitors (DRI), or Sodium-glucose co-transporter-2 (SGLT2)
inhibitors.
[0075] In other embodiments, the methods can be used to personalize
initiation and continuation of therapy based on personal
clinicopathologic characteristics of the specific patient.
Non-limiting examples of personal clinicopathologic characteristics
comprise the measured plasma renin activity assayed and defined as
PRA, PRAC, ARC, PRAC and/or APRC or other methods, pro-renin
activity, PRR levels, extracellular water content, total water
content, lean muscle, fat mass, heart rate, heart rhythm, sex, age,
history of diet, exercise, smoking, and/or heart dysfunction
specific to the patient.
[0076] In preferred embodiments, plasma renin activity is assayed
and defined as PRA, PRAC, ARC, PRAC and/or APRC or other methods;
and pro-renin activity PRR levels are measured using standard
laboratory assays described herein.
[0077] In some embodiments, the present invention features a method
for prolonging life. Non-limiting examples of prolonging life
comprise prolonging life by at least 1 month, at least 3 months, at
least 6 months, or at least 1 year or greater, for personalizing
initiation and continuation of therapy, for determining the onset
of the condition (e.g., HF, liver disease, kidney disease,
muscle/fat-wasting or cachexia/sarcopenia). In appropriate
circumstances, the method is for reducing the progression of heart
dysfunction and diminishing HF, delaying the transition from heart
dysfunction to clinical HF, as well as for a self-monitoring method
and/or self-modifying of treatments. Other embodiments of the
present invention may feature a method that can be used as a
Companion Diagnostic for a specific treatment for a condition that
causes or is caused by elevated plasma renin, heart dysfunction,
HF, and/or a HF-related condition. Another embodiment may feature a
method for stratifying patients with HF or those at risk for HF to
determine appropriate medication or therapeutic intervention(s) and
dosage of medication or augmentation to intervention(s) to treat
further progression of HF.
EXAMPLES
[0078] The following are non-limiting examples of practicing the
present invention. It is to be understood that the invention is not
limited to the examples described herein. Equivalents or
substitutes are within the scope of the invention.
Methods:
[0079] Mice: In the Examples 1-3 below, the mice used were all
female littermates with or without dilated cardiomyopathy (DCM) on
a C57BL/6 background. DCM is a major cause of HF, which is
associated with pathological dilation of the heart ventricles and
declines in heart contractile or systolic function. DCM mice
express transgene dominant negative CREB transcription factor,
specific to cardiomyocytes and develop a consistent progressive DCM
and HF similar to humans. In female mice with DCM renal function
remains within normal range up to the terminal HF stage, as
measured by plasma BUN and creatinine. DCM mice (mCREBTg) are
slightly hypotensive at 91 days of age compared to mCREB WT. mCREB
mice were randomly assigned to experimental groups. Groups were
denoted as WT (n=20), DCM (Control, n=28), and DCM+direct renin
inhibitor treatment (+DRI, n=29). At 90-day censorship, dissected
organs were weighed, and terminal blood was collected via
cardiocentesis with EDTA-aprotinin syringes to prevent proteolysis
of targeted proteins. The blood samples were centrifuged at 3000
rpm for 20 min at 4.degree. C. Plasma samples were aliquoted and
stored at -80.degree. C. until analysis.
[0080] In Example 4 below, female and male mice were used as
indicated in FIG. 4 description. The direct renin-inhibitor group
(DCM+DRI) was administered aliskiren hemifumarate (BOC Sciences,
Shirley, N.Y., USA) at 100 mg/kg/day orally via single source
drinking-water in autoclaved hanging bottles. Dose calculations
were based on an average consumption of 5 mL of water/day/mouse.
The bioavailability of aliskiren is low in humans and only 2.6%
orally in rats. Previous studies administering 15-50 mg/kg/day via
subcutaneous osmotic pumps showed no alteration in blood pressure.
The oral dose was chosen to closely mimic the human route of
delivery, while not altering the blood pressure, associated with
elevated plasma Ang II-aldosterone levels, given the low
bioavailability of the drug in rodents. To prepare the solution,
aliskiren powder was dissolved by shaking in volume measured
autoclaved 3 ppm hyperchlorinated facility water, mixed fresh every
72 h and shaken daily to resuspend. No issues with palatability or
clinical dehydration were noted throughout the study as assessed by
blinded husbandry and veterinary staff. There were no side effects
or abnormal clinical observations in the mice throughout the
treatment period. The aliskiren in drinking water was well
tolerated and consumed at expected levels for plain water. The
administration was started at 50 days of age to coincide with the
previously identified timeline of increased renin activity and
development of stage B HF in female DCM mice]. Aliskiren water was
provided ad libitum throughout life. All untreated mice (WT and
DCM+vehicle) received ad lib 3 ppm hyperchlorinated facility water
via an automated watering system (Edstrom, Waterford, Wis.,
USA).
[0081] Echocardiography: The standard transthoracic exam was
performed using a Vevo 2100 Imaging System (VisualSonics; Toronto,
ON, Canada) with a 30 MHz transducer (MS 400). All imaging was
performed at 90 days of age (mice were treated for 35 days before
subjecting to echocardiogram). Briefly, mice were induced with 3-5%
isoflurane in oxygen and fur removed with depilatory cream (Nair,
Church & Dwight Co. Inc., Princeton, N.J., USA). Maintenance
anesthesia was held at 2% isoflurane in oxygen throughout the
two-dimensional and M-mode recordings of the left ventricle (LV) in
parasternal long-axis, short-axis, and four-chamber views. Mouse
physiology was maintained at an anesthetized heart rate of
450.+-.50 beats per minute and 37.+-.1.degree. C. rectal
temperature. The analysis was blindly completed post-recording
using Vevo LAB software (3.1.0, VisualSonics) with three cardiac
cycles traced to produce mean values. Ejection fraction (EF, %),
fractional shortening (FS, %), LV mass corrected (LVMc, mg), and
cardiac output (CO, mL/min) were calculated using standard
equations within the software.
[0082] Enzyme Immunoassay: Plasma Ang II, aldosterone, atrial
natriuretic peptide (N terminus-ANP), cyclic guanosine
monophosphate (cGMP), neprilysin, and corin levels were measured by
enzyme immunoassays according to the manufacturers' protocols
(Phoenix Pharm. Inc., Burlingame, Calif., USA; Abcam Inc.,
Cambridge, Mass., USA; Enzo Life Sciences Inc., Farmingdale, N.Y.,
USA; Boster Biological Technology, Pleasanton, Calif., USA; USCN
Life Science Inc., Houston, Tex., USA).
[0083] Plasma Renin Activity Assay: Renin enzymatic activity from
EDTA-aprotinin supplemented mouse plasma samples were measured in a
96-well microplate (Synergy HT reader and Gen5 v1.09 software,
BioTek Instruments, Inc., Winooski, Vt., USA) and quantified using
exogenous fluorescence resonance transfer (FRET) peptide substrates
of renin FRET-QXL.TM.520/5-FAM, optimized for mouse renin
(SensoLyte.RTM. 520 mouse renin assay kit, AnaSpec, Fremont,
Calif., USA). Cleavage of the FRET substrate by mouse renin results
in the recovery of quenched fluorescence of 5-FAM, which was
detected at excitation/emission=490/520 nm with minimum
autofluorescence of plasma samples. The 5-FAM fluorescent reference
standard curve was used for results quantification. It is important
to note that the PRAC assay differs from PRA and ARC/APRC, which
have been historically used to report active renin in clinical
trials.
[0084] Statistical Analysis: Statistical analyses were performed
with GraphPad Prism 7.04 software (GraphPad Software, La Jolla,
Calif., USA) using Student's t-test, one-way ANOVA, or two-way
ANOVA with Tukey's multiple comparisons test (unless otherwise
indicated) and Pearson's correlation. Survival was analyzed using
Kaplan-Meier curves with the Mantel-Cox test. Differences were
considered significant if p.ltoreq.0.05. The number of animals (n)
is indicated in the figures or figure legends. Data are represented
as mean.+-.SE.
Example 1: Suppression of Elevated Plasma Renin Activity in Females
with Dilated Cardiomyopathy (DCM)
[0085] FIG. 1A shows HF development from Stage A (no HF), to Stage
B (structural heart disease), through Stage C (edema, symptoms),
Stage D (severe HF) and death. Female mice with DCM begin to show
declines in heart systolic function (ejection fraction; EF) and
increases in PRA around 7 weeks of age (Stage B HF), which is prior
to the development of progressive edema, further declines in
systolic function, rises in atrial/B-type natriuretic peptide
(ANP/BNP) and death (FIG. 1A). Female littermate mice with DCM were
randomly assigned to receive no treatment (control) or the direct
renin inhibitor (+DRI) aliskiren. Treatment with the DRI
significantly reduced elevated PRA to normal levels as expected
(P<0.01, FIG. 1B). Pathologically elevated plasma aldosterone
levels were not modulated by treatment (FIG. 1C). The aldosterone
to renin ratio was significantly increased in +DRI mice vs.
controls (P<0.05, FIG. 1D).
Example 2: Renin Activity Suppression Prolongs Survival and Delays
Progression of Left Ventricular Systolic Dysfunction
[0086] The effect of plasma renin activity suppression was assessed
in female mice with DCM as they pass progressively through the
stages of HF development from Stage A (no HF), to Stage B
(structural heart disease), through Stage C (edema, symptoms),
Stage D (severe HF) and death. Three groups of female littermates
were examined--DCM control, DCM+DRI and WT mice. WT littermates had
100% survival throughout the 140 day study (data not presented).
+DRI mice outlived the control mice by 7% (median survival--110 vs.
103 days respectively, P<0.05, FIG. 2A). In the same
experimental groups, cardiac structure and function were assessed
by echocardiography at 90 days (Stage C HF with respect to control
group). Systolic function in control mice was improved with DRI
treatment as measured by ejection fraction (EF %, P<0.05, FIG.
2B) and fractional shortening (FS %, P<0.05, FIG. 2F). Cardiac
output (CO mL/min) was also improved with DRI treatment (P<0.01,
FIG. 2C), reflecting changes in both heart rate (control 419.+-.10
bpm vs. +DRI 469.+-.14 bpm, P<0.01) and changes in stroke volume
(control 11.+-.1 .mu.L vs. +DRI 16.+-.1 .mu.L, P<0.05).
Contractile function assessed at 90 days by EF (r.sub.p=0.47.
P<0.001, FIG. 2D) and CO (r.sub.p=0.53, P<0.05, FIG. 2E) were
positively correlated with survival outcome.
Example 3: Heart Failure Plasma Biomarkers Independently Respond to
DRI Treatment
[0087] HF biomarkers were measured in a subgroup of mice at 90
days. As expected, ANP (P<0.01, FIG. 3A) and cyclic guanosine
monophosphate (cGMP, P<0.01, FIG. 3B) levels were elevated,
while plasma corin levels were reduced (P<0.01, FIG. 3C) in
control groups vs. WT littermates. ANP and corin plasma levels were
not affected by DRI treatment (FIGS. 3A, 3C). Plasma cGMP levels in
+DRI group showed a non-significant trend toward lower levels (FIG.
3B). Neprilysin levels were increased in controls compared to WT
(P<0.05) and +DRI groups (P<0.001. FIG. 5D). DRI-aliskiren
treatment lowered neprilysin to WT levels.
Example 4: PRAC Increases in a Sex-Dependent Manner Throughout the
Course of HFrEF Progression
[0088] Similar to humans, DCM mice pass through all four Stages A-D
of HF in a sex-related manner from Stage A (risk without
abnormalities) to progressively declining contractile function and
increasing heart dilation (Stage B) to the development of
peripheral and pulmonary edema and pleural effusions with increases
in plasma ANP and BNP (Stage C) to the onset of severe HF and death
(Stage D). Pathological PRAC, plasma Ang II, and aldosterone levels
increased with the progression of systolic dysfunction, cardiac
remodeling, edema, and stages of HF in a sex-related fashion (FIG.
4). Despite elevated PRAC levels, systolic and diastolic blood
pressure were not elevated and kidney function (plasma BUN and
creatinine) was within normal limits (data not shown). In female
mice with DCM, the pathological rise in PRAC levels preceded the
development of edema (Stage C) and likely contributed to the early
demise of female versus male DCM mice (median survival 13.8 verses
20 weeks). Although the RAAS may be affected by sex, ovariectomy
did not influence PRAC, systolic function, lung water retention,
and survival. Potentially, the increased PRAC levels in female mice
with DCM may be driven by sex-related differences in upstream
pathways related to the kinin-kallikrein/Factor XII network, which
may regulate enzymatic prorenin activation.
Example 5: Schematic Representation of the Potential Role of Renin
Activity in the Modulation of Heart Failure with Reduced Ejection
Fraction (HFrEF) Via Direct and Indirect Effects
[0089] Further complicating the physiology of renin is that it has
systemic and local effects within the heart. As shown in FIG. 5,
proteolytic and non-proteolytic conversions of prorenin to
enzymatically active renin exist. Enzymatically active renin has
the potential to directly modulate HFrEF progression through
binding with receptors such as the (pro)renin receptor and/or
IGF-2/M6P receptor. It can also act indirectly through the
generation of Angiotensin I (Ang I), which acts through the
angiotensin converting enzyme (ACE)-angiotensin II (Ang II)/Ang II
type I receptor (AT1) and neprilysin (NEP)/Angiotensin Converting
Enzyme 2 (ACE2)-Angiotensin (1-7) (Ang (1-7))/Mas axes or possibly
Ang II type 2 receptor (AT2) (*).
Example 6: Renin Activity as a Diagnostic and Prognostic Marker
[0090] Plasma renin activity (PRA) and active renin concentration
(ARC) longitudinally increase with HF stages in experimental HF to
become pathologically elevated in symptomatic HF; levels of each
vary between subsets of HF patients with reduced ejection fraction
(HFrEF). The present invention establishes the diagnostic and
prognostic value of renin enzymatic activity as a predictor and/or
modulator of pre-symptomatic and symptomatic HFrEF, as well as its
value for guiding therapy in the absence or presence of a RAAS
blockade.
[0091] Assays of PRA: FIG. 6 shows a schematic presentation of
assay principles used to measure enzymatic renin activity in plasma
samples: PRA; ARC/APRC; and PRAC. Experimental studies of renin
activity in patients with HFrEF are challenging; patients are
heterogeneous, often receive treatments that may modify renin
activity, and may have additional comorbidities which
differentially affect experimental interventions during clinical
trials. For example, therapies that modulate Ang II/aldosterone
production and activity affect prorenin/renin levels, renin
activity levels, and the potential effects of renin-targeted
treatments.
[0092] Although circadian rhythm does not affect plasma renin
activity levels, physical activity might. Thus, patients are
recommended to sit 10-15 minutes prior to blood collection.
Precautions should be taken during blood sample collection,
storage, and handling over assay performance to prevent in vitro
proteolysis of prorenin/renin and the non-proteolytic conversion of
prorenin to active renin by cryoactivation and/or low pH.
Cryoactivation is the process of irreversible conversion of
prorenin to active renin in cooled, unfrozen plasma due to
unfolding of the prorenin prosegment followed by its cleavage by
plasma proteases. Considering that the concentration of prorenin in
plasma is more than 10-fold greater than active renin, even a small
modulation of the prorenin/active renin ratio in vitro might
significantly compromise the final measurements. Importantly,
techniques and assay protocols used to measure renin activity
differ between HFrEF clinical studies (FIG. 5), which may impact
major conclusions. Reference ranges for renin plasma activity vary;
they depend on assay method and differ between commercially
available kits.
[0093] Ang I Generation Assay: Traditionally in clinical studies,
renin enzymatic activity, abbreviated as PRA, is assayed by a
2-step process measuring the potential of a patient's plasma sample
to convert exogenous angiotensinogen (substrate) to Ang I (product)
during in vitro incubation, followed by measurement by
radioimmunoassay (RIA) or enzyme-linked immunosorbent assay (ELISA)
of the generated Ang I. However, the Ang I generation step is
time-consuming and time-sensitive. Depending on active renin levels
in plasma, this step might take from 3 to 18 h. Moreover, PRA
measurements could be altered by the amount of endogenous
angiotensinogen level in plasma samples.
[0094] Immunoassay for Active Renin: The second method for
estimation of enzymatically active renin in plasma samples is
angiotensinogen-independent and technically more convenient. This
assay measures an active renin concentration, abbreviated as
ARC/APRC, using an antibody that is specifically directed against
the active site of renin and therefore, capable of distinguishing
active renin from inactive prorenin. In general, these assays use
principles of sandwich immunoassay; monoclonal capture antibody
recognizes both active renin and prorenin, followed by a detection
step with a labeled monoclonal antibody toward active renin.
Several detection systems have been developed and are comprised of
either manual or automated immunoassays for the quantification of
ARC/APRC.
[0095] Renin-Specific Substrate Cleavage Assay: An alternative
strategy for renin enzymatic activity quantification utilizes
exogenous fluorescence resonance transfer (FRET) peptide substrates
of renin based on the octa- to deca-peptides derived from the
N-terminal sequence of angiotensinogen, labeled with
quencher/fluorophore pairs--DABCYLIEDANS, Dnp/Amp, or
QXL.TM.520/5-FAM (SensoLyte 390 or SensoLyte 520 assay kit,
AnaSpec, Fremont, Calif., USA). Cleavage of the FRET substrate
results in the recovery of quenched fluorescence that can be
directly monitored and conveniently quantified. Results of this
assay are expressed as active enzyme concentration in nM or ng/mL.
The QXL.TM.520/5-FAM pair is superior to the other two: 5-FAM
fluorophore has higher brightness and stability, and its
fluorescence can be monitored with minimal autofluorescence
background of test compound, cell components and plasma proteins
(SensoLyte 520 assay kit, AnaSpec, Fremont, Calif., USA). The
FRET-QXL.TM.520/5-FAM peptide substrate was optimized by AnaSpec,
Inc. for human, mouse, or rat renin. Specificity of substrate
cleavage was validated with several known renin inhibitors.
Commercially available kits containing FRET-QXL.TM.520/5-FAM
substrates are designed for in vitro screening of renin inhibitors,
are marked "for research use only", and are not validated by the
company to measure renin enzymatic activity in plasma. Hence,
normal values and ranges for renin are not established for this
assay, and clinical comparisons with PRA and ARC assays have not
yet been performed. Although nonspecific cleavage of this FRET
substrate in plasma could not be excluded, a supplementation of
plasma samples with a combination of ethylenediaminetetraacetic
acid (EDTA) and serine protease inhibitors phenylmethylsulfonyl
fluoride (PMSF) or aprotinin chelates zinc/calcium ions required
for activity of ACE and angiotensinase A and inactivates chymases
and angiotensinase B. FRET-QXL.TM.520/5-FAM containing kits were
successfully adopted by several laboratories for the direct
measurement of plasma renin enzymatic activity. Importantly, the
assay detected changes in PRAC relative to pathophysiological
stresses associated with renal autograft ischemia-reperfusion
injury, response to ARBs in normal and diabetic C57BL/6 mice, and
chronic suppression of PRA in experimental mouse model of HFrEF
with DRI aliskiren. This assay is abbreviated as PRAC in order to
distinguish from PRA and ARC/APRC.
[0096] Prognostic Value of PRA in HFrEF: Over the past decade, the
prognostic value of PRA in HF has been extensively evaluated and
reported. PRA was reported to be an independent prognostic marker
in prospectively enrolled patients with HFrEF (n=996), irrespective
of medical treatment, which was additive to N-terminal-prohormone
B-type natriuretic peptide (NT-proBNP) levels and ejection fraction
(EF). The independent prognostic value of PRA was reported for
chronic HF patients with chronic kidney disease comorbidity. PRA in
combination with NT-proBNP plasma levels identified a subgroup of
high-risk patients, who might benefit from more intensive care.
Higher PRA levels were associated with a greater likelihood for
prevalence of congestive HF in a large diverse cross-sectional
study on hypertensive individuals. Elevated PRA levels demonstrated
increased risk for congestive HF and a trend toward higher
mortality among patients with systolic blood pressure (SBP) 140
mmHg, but this was not true for individuals with SBP <140 mmHg.
PRA was significantly elevated in ambulatory chronic HFrEF patients
and in acute HFrEF patients. All trials described above contain
patients with concurrent HF medications (ACE-I, ARB, ARNi, etc.).
The Studies of Left Ventricular Dysfunction (SOLVD) trial showed
groups (control vs. HFrEF) could be stratified based on elevated
PRA levels without prior exposure to ACE inhibitors but did not
exclude diuretics. Similarly, others reported that HFrEF patients
on diuretics were more likely to have elevated PRA. However, the
results from Val-HeFT trials report that PRA remains a prognostic
marker even in the presence of ACE inhibitors, which are known to
increase PRA levels. ARC was reported to be superior to PRA for the
evaluation of HF severity and for independently predicting survival
in HF patients who were hospitalized for management of HFrEF and
were already on ACE inhibitor or ARB medications. Most recently,
ARC was found to be a potential biomarker for HFrEF, which had
value in addition to NT-proBNP and NYHA classification, to
subclassify HFrEF patients receiving RAAS blockers into HFrEF
phenotypes that required adaptive therapeutic interventions.
[0097] Although differences between PRA and ARC/APRC are not
clearly established in HF, specific measures of plasma renin
activity can be useful for identifying individuals for whom
titrated doses of renin inhibitors may attenuate the progression of
HFrEF as described herein.
[0098] The present invention (FIGS. 7A-7B) shows that a
pathological elevation of PRAC precedes the development of edema
(symptomatic HFrEF) in a subset of patients with reduced systolic
function with or without symptomatic HF (FIG. 7A). There was no
significant difference in medical management between rEF groups
with or without symptomatic HF; an equal percentage of patients
received beta-blockers, ACE inhibitors, or ARBs. Patients with a
significant increase in PRAC levels compared to healthy controls
might benefit from the addition of DRI to standard HF therapy.
Patients in this study were characterized by enzymatic
downregulation of the NP system, with elevated plasma levels of
NEP, atrial natriuretic peptide (ANP), B-type natriuretic peptide
(BNP), and cGMP and reduced plasma levels of the pro-natriuretic
peptide convertase, corin. There was a positive correlation between
PRAC and plasma N-terminal-pro atrial natriuretic peptide (N-ANP)
(FIG. 7B).
[0099] The above examples performed in a translationally-relevant
model of HF re-evaluated the role of plasma renin activity in the
progression of HFrEF and show that targeted suppression of plasma
renin activity significantly prolongs life and preserves left
ventricular function. This is the first evidence that targeting a
sex-related difference in plasma renin activity levels
significantly diminishes deterioration in cardiac function, edema
formation, tissue loss and early mortality.
[0100] Through vasodilation, natriuresis and other mechanisms, the
NP system opposes the effects of active renin in HF. The present
invention shows that suppression of pathological PRAC normalized
plasma neprilysin and induced a trend towards normalization of cGMP
levels, but did not affect plasma ANP and corin levels. This is
notable, as elevated plasma neprilysin and cGMP levels reflect
symptomatic HF, while low corin levels may reflect systolic
dysfunction, independent of HF clinical symptoms (i.e., edema) in
humans and mice with DCM. Elevated plasma neprilysin levels are
associated with enhanced mortality in clinical HF, thus the fact
that normalization of pathological plasma renin activity level
reduced neprilysin levels is consistent with its effects on
prolonging survival.
[0101] Although DRI-aliskiren at 100 mg/kg normalized pathological
renin activity, there was no significant difference in plasma Ang
II and aldosterone levels between DCM+vehicle and DCM+DRI groups.
However, it cannot be excluded that aliskiren may suppress cardiac
Ang II production as reported in diabetic rats. This lower dose DRI
treatment normalized plasma neprilysin levels. Lower neprilysin
levels are associated with reduced degradation of NP and of
angiotensin (1-7), which promotes vasodilation and sodium
excretion. Although active neprilysin cleaves NP, there was no
correlation between levels of immunoreactive NP and immunoreactive
neprilysin, which has also been noted in previous studies of HF
patients. Additionally, aliskiren may provide cardiac protection
through induction of increased cardiac bradykinin levels. Studies
also suggest that renin may modulate HF through direct stimulation
of (pro)-renin signaling receptors independently from the
angiotensinogen-angiotensin axis. The present invention is designed
to show the direct pathophysiologic effects of elevated plasma
renin activity in HFrEF progression. In some embodiments, DRI
therapy may be co-administered with other drugs used for HF.
[0102] In summary, although there are important differences between
patients, nearly everyone with HFrEF is currently treated with the
same medications. Previous studies evaluating renin activity as a
predictor of HF in pre-symptomatic patients are lacking. Most prior
studies examining DRIs have defaulted to the traditional
hypertensive doses of 150-300 mg/kg/daily rather than considered
the benefits of lower doses observed from the experimental studies
(as described herein). The present invention shows that normalizing
the increased plasma renin activity concentration in experimental
HFrEF (using lower doses compared to traditional hypertensive doses
and oral administration) significantly improved systolic function,
delayed the onset of edema, and significantly extended survival.
The present invention described herein supports that increased PRA
has deleterious effects in HF and suggests that, in appropriately
identified individuals, the normalization of PRA has protective
effects by delaying the transition from early, asymptomatic to more
severe and fatal HF. In preferred embodiments, renin activity is
used as a reliable HFrEF biomarker and bio-target. The optimal
method of diagnosing and monitoring enzymatic renin activity levels
in patient plasma samples allows for improved outcomes through the
use of individualized/precision medicine approaches in HF clinical
management.
Example 7: Effect of Cardiac Corin-Tg(i) Overexpression on HF
Plasma Biomarkers
[0103] Systemic activation of the renin-angiotensin-aldosterone
system (RAAS) occurs in HF with increased plasma renin activity,
angiotensin II and aldosterone levels. Systemic RAAS is
significantly activated in female mice with DCM starting from Stage
B HF. Plasma renin activity, angiotensin II and aldosterone levels
were significantly elevated in corin-WT/DCM mice compared to normal
levels in corin-WT/WT littermates (FIGS. 8A, 8B, and 8C). In
corin-Tg(i)/DCM mice plasma renin activity (p=0.55, FIG. 8A) and
angiotensin II plasma levels (p=1.0, FIG. 8B) were not
statistically altered, while aldosterone plasma levels had a
non-significant decrease and a trend towards normal levels (p=0.07,
FIG. 80). Plasma levels of angiotensin (1-7) were not altered by
corin-Tg(i) overexpression (p=0.7, FIG. 8D).
Example 8: Dietary Sodium Restriction Stimulates Systemic Classical
RAAS and Counter-Regulatory RAAS without Affecting Blood Pressure
and Renal Function
[0104] The impact of a low sodium diet (LSD) on classical and
counter-regulatory systemic RAAS, blood pressure and renal function
was evaluated in DCM mice at 17 weeks of age. Plasma renin
activity, angiotensin II and aldosterone levels were not
significantly elevated in DCM mice vs. non-DCM WT controls on a NSD
(FIGS. 9A, 9B, and 9C). However, these plasma markers were
significantly upregulated in DCM mice on a LSD vs. WT controls
(p<0.001 for both FIGS. 9A and 9B; and p >0.0001; FIG. 9C).
Similarly, plasma renin activity (p<0.05; FIG. 9A), angiotensin
II (p<0.01; FIG. 9B) and aldosterone levels (p<0.0001; FIG.
9C) were markedly increased in DCM mice on a LSD vs. normal sodium
diet (NSD). In parallel, plasma levels of non-canonical RAAS
markers ACE2 and Ang (1-7) were significantly higher on a LSD vs.
NSD or by comparison to WT mice (p<0.0001; FIGS. 9D and 9E).
Example 9: Longitudinal Measurements of PRA and Treatment Strategy
for Changes in PRA
[0105] A 55-year-old male patient has his annual physical from his
primary care physician. In addition to the standard test and
physical exam, his physician orders blood work to measure the
patient's plasma renin activity (PRA) level. This establishes the
baseline level of the patient.
[0106] One year later, the patient comes to get his yearly physical
which includes mearing his PRA level. After the exam, when the
physician receives the blood work results, the physician notices
that the patient's PRA level has increased by 10% compared to the
PRA base line level, which concerns the physician. The physician
orders more testing and the results show that the patient has a
heart condition. The physician prescribes a drug treatment to the
patient and asks that he return in 6 months for a follow-up
appointment. After six months the patient's PRA level is measured
again, unfortunately, no progress has been made in lowering his PRA
level. The physician decides to change the patient's treatment by
prescribing another drug, and again asks that he returns in 6
months for a follow-up appointment. Again, the patient returns
after 6 months to have his PRA level measured. The physician
determines that with this treatment, the PRA level has decreased by
5%. Pleased with this response, the physician recommends that the
patient remains on this treatment, with follow-up appointments
every 6 months. After 2 years of treatment, the patient's PRA
levels have normalized back to his baseline.
[0107] Although there has been shown and described the preferred
embodiment of the present invention, it will be readily apparent to
those skilled in the art that modifications may be made thereto
which do not exceed the scope of the appended claims. Therefore,
the scope of the invention is only to be limited by the following
claims. In some embodiments, the figures presented in this patent
application are drawn to scale, including the angles, ratios of
dimensions, etc. In some embodiments, the figures are
representative only and the claims are not limited by the
dimensions of the figures. In some embodiments, descriptions of the
inventions described herein using the phrase "comprising" includes
embodiments that could be described as "consisting essentially of"
or "consisting of", and as such the written description requirement
for claiming one or more embodiments of the present invention using
the phrase "consisting essentially of" or "consisting of" is
met.
* * * * *